(only person to use this e-mail is Dr. Powell. NO ONE ELSE will get your address)

Home Phone:

Home Phone:

(###)

###

####

Cell Phone:

Cell Phone:

(###)

###

####

Birthdate:

Birthdate:

MM

DD

YYYY

How many Children?

If yes, ages?

Education:

(Circle the highest level achieved)

Employment Information

Patient Employer:

Occupation:

Employer Address:

Employer Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Work Phone:

Work Phone:

(###)

###

####

Ext.

Social Security:

Drivers License:

In Case of Emergency

Name 1

Name 1

First Name

Last Name

Relationship:

Phone:

Phone:

(###)

###

####

Patient's Spouse:

Phone:

Phone:

(###)

###

####

Family Physician:

Phone:

Phone:

(###)

###

####

Referred by:

Financial Policy

Thank you for selecting Physician’s Plan Weight Management for your health care needs. We are
honored to be of service to you and your family. This is to inform you of our billing requirements
and our financial policy. Please be advised that payment for all services will be due at the time
services are rendered, unless prior arrangements have been made. For your convenience, we
accept Visa, MasterCard and checks.
I agree that should this account be referred to an agency or an attorney for collection, I will be
responsible for all collection costs, attorney’s fees and court costs.

By signing my name below I have read and understand all of the above and have agreed to these statements. *